Waiting to Inhale

MARNI WAHLER

Published 4:00 am, Sunday, August 9, 1998

Eleven years ago, Mariana Tovshteyn decided to surprise her husband. Back from work, he opened the door to their cream-colored home in the Sunset district and stopped in his tracks. Every square foot of carpeting was gone. Over the next few years, Mariana had the hardwood floors refinished, the old drywall ripped out, all bedding zipped in plastic cases, and the central heating system replaced with electric wall panels. Each month, armed with an arsenal of spray chemicals, Mariana attacks the microscopic dust mites, pollen grains and mold spores that cling to surfaces throughout her house. "I'm getting so paranoid that when I see dust, I get the shakes," she says. "I have not found a sterile place. I have lived in hotels, I've tried everything." Yet even these moves only offered brief respites - what Mariana calls "honeymoons." While the piano sits silently in the foyer, the hum of air cleaners harmonizes, Zen-like, on each floor. And a trail of asthma medications, from pills to inhalers, weaves through the house, starting in a cabinet under the bathroom sink. "Welcome to the Walgreen pharmacy," Mariana says. Mariana's daughter, Rebecca, will be 12 at the end of this year, but is petite enough to be mistaken for a 9-year-old. Only her eloquence and ability to recite an entire litany of asthma medications and rituals remind grownups that she's nearly a teenager, albeit already far more responsible than most. Rebecca has had moderate to severe asthma since she was about 2. She takes up to six medications daily to keep her asthma in check and has a respirator in her room to help open her airways when they become inflamed - usually in the middle of the night. No one would imagine this scenario if they saw her in her martial arts class, or in the swimming pool. But an hour and a half outside, says her mother, usually results in an attack. And a game of indoor tag lasts a brief 15 minutes before Mariana begins to hear coughing, and giggles are replaced by wheezes. Though her younger daughter's asthma is well under control with a minimum of medications, Mariana still worries about Rebecca. She'll never forget the many times Rebecca has shaken her awake at 3 a.m. - blue-faced, drenched in sweat, gasping for breath. "I haven't slept for 10 years," says Mariana. She's not alone. Doctors are also burning the midnight oil, stumped by the latest reports from pediatric wards across the country. More kids have asthma than ever before. Considered the most chronic disease of childhood, asthma affects approximately 5 million children under 18 in this country. The National Institutes of Health (NIH) reports that 1 child in every 15 has the disease, and the number is growing, as is the number of asthma-induced deaths, which doctors attribute to undertreatment and poor access to healthcare. The National Asthma Education and Prevention Program reports that between 1982 and 1993, asthma increased 80 percent among children in the United States. The latest theories blame this increase on the very way we live: More time indoors, less time outside exercising, and easy access to broad-spectrum antibiotics upon birth. Though asthma has been studied since the days of Hippocrates, myths persist: the most common being that it is a disease of the weak or a product of the imagination.

"It was at one time thought to be a psychosomatic disease, even among quite reputable psychiatric circles in the 1950s," says Dr. Homer Boushey, a professor of medicine at UCSF who has been studying asthma for 25 years. "And because of this mythology that asthma is psychosomatic, that it reflects a weakness in character, there are some tragic stories." Boushey cites one study of children who died from asthma in New Zealand. A common finding of the study was a delay in seeking care, due to a parental "just-buck-up" attitude. "We now know that it is a disease of altered immune function and airway inflammation," says Boushey. Asthma is a chronic disease of the passageways that carry air to the lungs. These passageways become narrow and the linings inflamed. The result is episodes of coughing, wheezing, chest tightness and shortness of breath. Symptoms occur because the inflammation makes the airways overreact to a variety of stimuli, or triggers, such as physical activity, upper respiratory infections and irritants like cigarette smoke and sulfur dioxide. The airwaves also react to triggers called allergens, substances such as house-dust mites, pollen, pet dander and mold that cause an immune response in the body that leads to allergic symptoms. And allergens, unlike other triggers, leave the airways even more sensitive after an episode has passed. Exposure to triggers creates more swelling and blocking of the airways and can lead to mild or life-threatening episodes. While there is no cure for asthma, there are effective treatments. In addition, parents can help children with a genetic predisposition to the disease avoid triggers once they have been identified.

The Home as Asthma Incubator

Dr. Thomas A.E. Platts-Mills, head of the division of asthma, allergy and immunology at the University of Virginia, Charlottesville, has been researching asthma for more than 30 years, concentrating his studies on the effects of indoor allergens. He has looked closely at changes in the Western lifestyle to better understand why asthma is increasing among children. A major factor in developed countries, says Platts-Mills, is that we have constructed houses so carefully that they've become hermetically sealed allergen chambers. The huge increase in time children spend in front of TV and computers, and the decrease in time they spend outdoors, exercising, just exacerbates the problem.

In 1980, researchers began to see an increase of asthma cases in England. They found that, since the end of World War II, houses had become more airtight, central heating had become the norm, and carpeting, which made its debut in the 1930s, was everywhere. All these conditions encouraged house-dust mites to multiply like mad. Researchers found that children who were predisposed to allergies and exposed to dust mites at a young age were very likely to become sensitized to them and develop asthma. Boushey says the main indoor allergens in the western United States are probably cat dander and house-dust mites. He's heard that more people in San Francisco have cats than in any other city in the United States. The dense housing here and the likelihood that owners work all day, have given cats an edge over dogs. Our coastal location also allows for relatively warm and moist air to gather, creating favorable conditions for dust mites. A family with a history of allergies, says Boushey, would be wise to decrease such indoor allergens. "There's a good deal of evidence that the amount of house-dust mites, or cat dander, or cockroach feces, or mold in the home is a determinant in a child born to a family with a history of allergies, which is about 30 percent of the population. The higher the levels of these allergens, the more likely the child is to have asthma." To reduce house-dust mite exposure, at-risk families should get rid of carpeting and install hardwood or linoleum floors, get covers for pillows and mattresses, and not have pets, especially cats. If they have a pet, Boushey says to keep it out of the child's bedroom.

"Those are simple and important measures," he says, adding that people with a history of allergies shouldn't smoke in those households. Also, mold growth is something to look out for in older homes in the foggier parts of the Bay Area. While Bay Area doctors concentrated on prevention and education, Platts-Mills continued to refine his theory. He began to notice that the increase in childhood asthma was generally limited to developed countries, if not to a single indoor allergen like dust mites. Yet if there was a strong association between indoor allergens and asthma, why wasn't asthma increasing in developing countries, where floors were made of dirt, humidity and bugs abounded, and cooking on an open fire was often done inside? In the rural, undeveloped villages of New Guinea, asthma remained rare; the same was true for villages in China. And people from undeveloped countries who moved to the West often developed asthma. He was no longer satisfied that indoor allergens were the only culprits. Platts-Mills then wondered if something in undeveloped countries was protecting people from wheezing - something that we had progressively lost. The researcher reasoned that either we were becoming allergic to things that we had previously ignored, or that our lungs were once protected by something in our behavior. "If we're looking for a lung-specific protective effect," he says, "then we're looking at something like exercise." In developing countries, he noted, children spent much more time outdoors, being physically active. While Platts-Mills acknowledges the prevalence of exercise-induced asthma in athletes, he thinks the increase in childhood asthma may be tied to a lack of exercise, ranging from the absence of random play to the failure of P.E. in schools. The shift away from physical activity began in 1950, he says, when technology gave birth to television and the world of visual entertainment. And more than ever, kids spend time passively, sitting in front of computers. While they may be exercising their brains, they're not physically active. "They're not doing exercise and they're not using their lungs," says Platts-Mills. "Now, the question is, could that have changed things?" Can parents help their kids prevent asthma by keeping them active and outside more hours each day? Platts-Mills says he can only hypothesize. "In my heart, I think that if we went back to the way we were living in 1950, things would improve. But then people would argue about which aspect of it. The only bit that makes sense to me today is something to do with physical exercise." Most local researchers agree that more time indoors may be one reason why so many children predisposed to asthma are developing it. Like Platts-Mills, they have seen exercise take a backseat to TV. But they aren't so sure that less physical activity is also putting children at risk.

Susan Janson, a professor of nursing at UCSF, sat on the NIH expert panel that published guidelines for the disease in 1991. She thinks the increase in childhood asthma is "probably due to intense exposures [to allergens] that are now occurring in the way we live." Not surprisingly, she traces much of this exposure to the home environment. As our society becomes increasingly violent, parents keep their children on a tighter lead. "Most of us who are adults grew up at a time when we could play outside all the time, freely," says Janson. "Now kids can't do that. It's not safe."

For children who can't play outdoors, computers and television become entertainment substitutes. Though parents don't need to supervise such activities as closely as outdoor play, they still need to think about total screen time, says Janson. "Total screen time is the time that you are locked inside an allergen-exposure chamber - and that's your house." Communities may need to band together to help supervise children, so that they can get outside more, says Janson, even if their own parents can't be home to watch them.

"This is where the it-takes-a-village- to-raise-a-child-notion comes in," she adds.

This is equally important to remember in school settings. In California, where academic performance continues to fall below the national average, students and teachers are working hard to raise test scores. But this may be taking away from the time they would otherwise spend outdoors.

"There's been an increased emphasis on using the time in school in a different way, less time spent outside, in P.E.," says Janson. "In fact the number of P.E. classes per week has dropped from daily to twice a week. In some cases, recess has been totally eliminated, because the belief is that kids might as well stay inside and work on the computer rather than go outside and play."

In California, says Tom McKenzie, a professor of exercise and nutritional sciences at San Diego State University, there have been cutbacks in the availability of physical education teachers due to Proposition 13. And while the state education code requires that elementary kids have an hour and 40 minutes of physical education each week, this code is not being followed. The bottom line, says McKenzie, is that parents need to get kids out of the house and ensure that their school requires daily physical activity. Boushey, like Platts-Mills, is also seeing a growing relationship between obesity, which could be linked to lack of exercise, and asthma. Researchers at the Harvard Medical School studied 100,000 U.S. nurses and found that obesity appears to increase the risk of developing asthma. Whether exercise can help prevent asthma remains to be seen, but exercise can benefit kids who already have asthma, says Dr. Sally Harris, head of the American Academy of Pediatrics section on sports medicine at the Palo Alto Medical Foundation. Kids who have their asthma under control can use exercise not only to improve their overall conditioning, but to improve their tolerance to physical activity. Ultimately, a higher level of activity would be required to trigger an attack. Another domain of indoor allergens and general illness is daycare, where indoor activities are increasingly popular and exposure is intense, notes Kayla Harvey, a nurse practitioner in the pediatric asthma clinic at the California Pacific Medical Center. "I know a lot of daycares try to focus on outdoor time, but I think for the most part they are in a closed-in space, kind of on top of each other. So that would promote more the exchange of viruses and that sort of thing." Harvey says children ages 1 to 4 years have had the highest increase in asthma among the pediatric age groups. Closed-in spaces may contribute to asthma differently in the very young. "These children are the ones who have the infection-related flare ups. So, the colds, upper-respiratory-tract infections and ear infections all seem to trigger and irritate the airways in the younger kids. It really isn't that these are the kids having the big allergy problems." Perhaps in another time, says Harvey, these children wouldn't have been in daycare and wouldn't have shared so many germs. Be it more time indoors or less time exercising, researchers are convinced that our highly evolved lifestyle is behind the increase in childhood asthma. But some think that Platts-Mills hasn't quite hit the mark.

Too Quick to Medicate?

University of Arizona pediatrics professor Dr. Fernando Martinez and other researchers theorize that the decrease in early childhood infections may have led to an increase in asthma. "What has occurred here is a dramatic change in the way we raise our children," says Martinez.

"Until not more than 100 years ago, 10 percent of all children who were born died within the first year of life." Respiratory and digestive infections were the main causes of death, but substantial improvement in hygiene and the availability of antibiotics have allowed for a much higher survival rate. For Martinez, the question is whether our survival has come at the cost of altering our immune systems in a way that makes us more susceptible to asthma. Our immune system needs to interact with the environment to learn how to respond to various stimuli and to mature, says Martinez. And this is especially important early in life, when the immune system encounters dangerous stimuli such as bacteria and viruses. These encounters shape the ways the immune system responds to infections in the future. Martinez says that researchers now know that we are most likely born with the ability to react in an allergic manner against most things we are exposed to. This includes allergens, which will produce allergies later in life. Researchers think that by encountering infections early in life, our immune system realizes there is a better, more mature, way to respond. That's through a nonallergic reaction. Martinez and others hypothesize that if our immune system does not go through this process, or does not go through it often enough, it will remain in an immature state. Kids with such immune systems will be more prone to allergies and asthma. In a study of a re-unified Germany, Martinez found that young East German children had lower rates of asthma than children in West Germany. The East German children spent far more time in daycare, grew up in cramped houses with more siblings, and did not receive broad spectrum antibiotics "as soon as they sneezed." The exposure to infections at young ages, Martinez thinks, steered the East Germans away from allergic reactions. But Martinez says he's not suggesting we return to the hygiene practices of a century ago or let infections fester. Rather, scientists want to find ways to imitate the effect that they believe infections once had on the immune system. And that effect was fewer allergies. Because scientists are unwilling to toy with a baby's fragile immune system, they are finding it hard to test this theory. But rodent studies have shown that introducing infection during the immune system's critical period of development helps it to mature and avoid allergic reactions, says Martinez. While there is evidence supporting the idea that the decline in respiratory tract infections may be related to the rise in asthma, Boushey says, it does not show a cause and effect relationship. "We have to be very careful before we even think about discarding the extraordinary important advances in preventing the consequences of severe respiratory tract infection," he adds. "And we need a lot more evidence before we should consider less aggressive treatment or immunization or prevention." But, he adds, clearly people whose family has a history of allergies should take measures to reduce domestic allergens, not increase infections.

Not Breathing Any Easier, Yet

Breathing seems so natural, so easy. Yet millions of children in this country cannot start the day without a puff from their inhaler. While their numbers increase, researchers remain puzzled. So, what do parents need to know if their child is diagnosed with asthma? "One, that asthma is an important disease," says Boushey. "And two, it's not due to errors in parenting."

Perhaps no one could agree more than Mariana Tovshteyn. By now, she's heard it all from relatives - that the asthma is going to go away, that just one source is responsible for it or that it's her fault. Her favorite piece of advice is,

"If you really loved your child, you would drop your job, root up, and move somewhere your child would feel better - like a desert." But after turning their lives upside down and their home inside out, Mariana and her family aren't holding their breath for any quick fixes.